Liposomal Doxorubicin in Suspected Ovarian Carcinoma Patient With Very Low Creatinine Clearance Test Value

Chinmoy K. Bose, MD, PhD; Banani Bose, MBBS, DRP; Amit Basu, MBBS, DGO, DICOG; Srabani Basu, MD

Disclosures

Medscape J Med. 2008;10(3):53 

A 74-year-old woman presented with moderate ascites with diagnostic features of adenocarcinoma of the ovary. She was given 1 course of cisplatin- and paclitaxel-based chemotherapy but did not have her creatinine clearance tested, which was consequently found to be very low. She subsequently presented with gross debilitating symptoms and toxicity. However, she tolerated 20 mg/m2 dose of liposomal doxorubicin every 4 weeks and was a good responder. Only 1 previous study of use of doxorubicin was found in such a low level of creatinine clearance.

A 74-year-old woman presented with moderate ascites and severe constitutional symptoms. She had a suspected ovarian tumor, most likely a carcinoma. Because of age, poor general condition, and high blood pressure, she could not be operated on by the last surgeon she had visited. Her abdominal sonogram showed a left-sided tumor mass of considerable size (10" x 12") highly suggestive of a malignant ovarian tumor. Abdominal paracentesis revealed poorly differentiated adenocarcinoma probably of ovarian origin. One month after this diagnosis, the patient presented to the study authors. She had moderate edema in both legs. Records indicated that her creatinine level was high normal during her previous work-up; however, the result of a creatinine clearance test was not available. She had severe anemia requiring transfusion of 7 units of whole blood. We administered a first course of paclitaxel/carboplatin. The patient then had severe chemotherapy-induced symptoms for which she reported to the study authors.

After symptomatic treatment and reassurance, the patient was admitted in a private hospital where she underwent all tests necessary for chemotherapy. Although everything was within normal range, her creatinine level was high. Most importantly, her creatinine clearance test revealed a value of 25.9 mL/hour, which can be classified as severe chronic kidney disease.

Considering this very low creatinine clearance value, we decided to go for doxorubicin chemotherapy.[1] Previously, epirubicin of the same group was proved to be safe in patients with renal compromise.[2] For efficacy, liposomal doxorubicin (LipoDox) was selected, but dose calculation for the same became problematic; 40 mg/m2 body surface area was suggested in company literature. In the literature supplied by the company, dose manipulation was indicated up to 30 mL/hour of creatinine clearance value, and it was mentioned specifically in their literature that there are no pharmacokinetic data available below that level of creatinine clearance. She weighed about 67 kg and her body surface area was 1.2 m2. Therefore, it was decided that 20 mg/m2 of LipoDox would be given at 4-week intervals. She was advised (by a medical specialist) in regard to supportive treatment with diet control (protein restriction) for her renal condition. From the third day, she visibly responded to the treatment. In fact, her metabolism improved. She became free from ascites and she regained appetite. She had several bouts of semiliquid purging, which gave her great relief. She could walk.

Subsequent to 6 doses of LipoDox 20 mg/m2, we found that her creatinine clearance had improved (32 mL/hour). Her blood count was stable. She tolerated the chemotherapy well. She had recurrence of her disease after a disease-free interval of 4 months, developed intractable ascites, and died due to cardiorespiratory failure.

This is one of only a very few case reports,[3] involving administration of LipoDox in a patient with renal compromise that is severe enough to be denoted as chronic renal failure. In the only other report, 7 cases of severe chronic kidney disease are described that had a creatinine clearance below 30 mg/hour. LipoDox was found to be useful in a patient with renal compromise. However, unlike that report, we did not find any complications of chemotherapy. This could be due to our dose adjustment and Indian body type.

The first author treated the patient, planned and designed the chemotherapy regimen, and wrote the article. The second and third authors assisted in treatment and worked as a team.

Written patient's consent was taken before treatment was undertaken, and she was explained thoroughly about her disease and treatment.


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